Tackling a touchy subject

I was a practicing pediatrician for several years before I finally became a parent myself. During this time period I was called upon to dole out all manner of advice, which I truly believed to have been helpful.  However, upon having a small person of my own to raise, I was immediately seized by a desire to call a great many parents and apologize for how worthless I almost certainly was.

It turns out that “this sounded sage during that conference I once attended” and “this helped preserve my sanity during a tense moment with my child” are not necessarily the same thing.  As a result of bashing my own expectations against the resilient rocks of my older child’s will, I have learned to temper my recommendations with a healthy dose of flexibility.  What works for one family falls totally flat with another.  Outside of a few hard and fast rules (vaccinate your kids!), I try to avoid a doctrinal approach to patient care.

With regard to my own kids, I also learned (or, perhaps more accurately, am learning) to eschew absolutes.  We have a rough idea of where we’d like to arrive as parents, and find ourselves meandering toward it rather that making the beeline I’d once thought possible.  Nowhere does the saying about the perfect being the enemy of the good hold more true than with regard to parenting, and as I am unmistakeably imperfect as a parent I am left to simply Do My Best.

Thus, I have issued very few parental edicts.  In fact, I can only think of two things that are completely non-negotiable as far as my kids are concerned.  (Maybe I’ll think of more as time goes by.)  One is that my kids are never, ever to drink unpasteurized milk.  That’s probably the kind of thing that wouldn’t even occur to most parents to have an opinion about, but I do and it is written in stone, chiseled there over the course of my medical training.

The other is that my son is never to play tackle football.

How this diktat goes over when he becomes a teenager remains to be seen.  I hope against hope that it’s as close to a non-issue as possible, but there’s no way of knowing how the Critter will respond if he wants to play football and I say no.  Because I will, without question, say no.  I see far too many kids every year with concussions, and the potential for serious or catastrophic injury is simply too great to be justified for the sake of a game.  Though I see lots of patients who have been hurt playing other sports, football surpasses them all.  (Hockey is a close second.)  He can play soccer, he can run cross-country, he can find some other sport if he has an athletic yen.  No football.

All of this sprang to mind the other day reading an article about Pop Warner football in Slate.  Writes Stephan Fatsis (who argues that young kids shouldn’t be playing at all):

 Last week, I took part in a roundtable discussion in Washington on the future of youth football. Robert Cantu, the CTE (chronic traumatic encephalopathy) researcher and NFL adviser, was there. So were Chris Nowinski, the Harvard defensive tackle turned pro wrestler turned brain-injury activist; neurosurgeon Julian Bailes, who has advised the NFL Players Association, the NCAA, and Pop Warner football; and DeMaurice Smith, the head of the NFLPA. An NFL executive attended, as did various youth-football organizations. There was an ex-Jet/Jaguar/Redskin, a plaintiffs’ lawyer, a school board member, the head of a sporting goods trade group, academics, and a bunch of journalists like me.


I know that Matt Chaney, who wrote for the roundtable this week about the tackling technique that won’t make football safer, is on board with the idea that tackle football is simply too dangerous for the brains of children, and that a distinction needs to be made between what adult men choose to do professionally and what kids are permitted or often pushed to do by parents and other adults. In his new book, Concussions and Our Kids, co-written with journalist Mark Hyman, Cantu proposes barring tackle football before age 14, or the start of high school. The cutoff is arbitrary, Cantu said at the Washington panel. The more important consideration is an individual child’s physical development: If he’s skeletally immature, if he hasn’t developed axillary hair, he shouldn’t play tackle football.


The third and most critical component of the youth-football defense wouldn’t be out of place at a debate over climate change: The science just doesn’t exist to justify banning youth football at any age level. Over and over, Hallenbeck cited the lack of “evidence-based” data. And while Cantu and others agreed that more research is needed, there’s already data that shows the effect of tackle football on undeveloped brains, like a study released this year by researchers at Virginia Tech and Wake Forest that found that 7-year-old players absorb impacts on par with those in college football. [emphasis mine]

Given my unapologetic opposition to my own child playing tackle football at any age, it is probably unsurprising that I don’t think preadolescent children should be playing it.  I think it is an utterly terrible idea, and if parents asked for my opinion outright then I would happily tell them so.

But often they don’t ask, and I find out their kids are playing tackle football as I take a routine history and inquire about exercise or extracurricular activities.  And I don’t tell these parents that I think their kids should quit.  Ought I?

The first reason why I don’t is indicated by the highlighted phrase above.  There really isn’t a clear body of evidence that indicates when tackle football is “safe” to begin.  As far as I can find, the American Academy of Pediatrics has taken no stance on the question, nor has any equivalent academic or medical body.  (I would be delighted to learn otherwise in comments, if anyone knows differently.)  While my clinical experience argues that football is too dangerous for small players and there is emerging evidence to support this impression, it is not as solid as I need it to be.

Why?  Because football is woven deep into the fabric of our popular culture, and these kids love their sport.  Telling them to stop playing is not a neutral action, but would (assuming they even take my advice) have a quality of life cost attached.  Furthermore, I have a finite treasury of credibility to spend on any given patient, and I have to be judicious with it.  How much should I pay out to prevent some unspecified number of theoretical injuries based mainly on my own inchoate hunches?

I do the next best thing, which is to go over in detail the signs and symptoms of concussion with every patient who plays football.  For those below a certain developmental threshold, I advise parents that the effects of concussion are even more poorly understood, so they need to be especially careful and conservative if they have even the slightest concern. For parents who evince ambivalence about whether their kids should be playing in the first place, I more freely share my concerns and say that my advice would be against it.  But I don’t try to sway people when they don’t seem interested.

I wonder, though, if I am failing in my ethical duties by not pressing harder.  At what point does “I just think it’s a bad idea” gain enough weight that I should put the heft of my professional recommendation behind it?  What if I am simply wrong, and new evidence indicates that younger players are at no increased risk compared to their older counterparts?

With my own child, the clarity of my convictions is enough.  My own best guess is sufficient justification for making all manner of parenting decisions as I see fit.  But my profession demands a different standard, and for now it seems best to me to keep my qualms to myself.

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


  1. My son will never play football either. I don’t care what his response is to this cruelty of mine; he won’t play.

  2. I know you think that parents should vaccinate their children but you shrink from requiring that they do so. Patient and parental autonomy are the weighty concerns motivating that stance, painful though it might be for you to see parents making what is (to you and me) an objectively risky and needless decision on behalf of their children. Why is tackle football any different?

    • First, I feel compelled to clarify that I think children should be required to have almost all recommended vaccines before being allowed to attend school. (I think you’re probably alluding to be thoughts about the HPV vaccine specifically, which I do not believe should be required for school attendance, even though I strongly recommend it for all my patients.) Do I feel they should be administered to children over their parents’ objection, by force if necessary? No, of course not. But I do think the burdens that accrue to such refusal should be significant.

      But I digress….

      I’m not really advocating that Pop Warner football be banned, even though I have serious concerns about it. I’m more concerned with my obligations to my patients. If my spidey sense warns against the safety of something, is that sufficient justification for recommending against an activity that many patients love? In the end, the decision will still rest with the parents, who are free (as in so very, very many things) to ignore what I say. But what is my obligation?

      • Russell –

        I had a conversation with a friend this weekend who has, thus far, refused to have her children vaccinated (ages 5 and 8). Her husband asked me to convince her that this was wrong-headed, but she says that her physician told her that vaccines cause autism (which flabbergasted me).

        Do you have any links to laymen-readable summaries of those large longitudinal studies that pretty much disposed of the vaccines-cause-autism hypothesis? I know that there is no statistical evidence linking them, but she is still open-minded enough about it to be persuadable.

          • There’s also a book put out by E. Allison Hagood and Stacy M. Herlihy entitled, “Your Baby’s Best Shot” which does a nice job of wading through myriad studies, etc. and making them more understandable for folks.

        • “Her husband asked me to convince her that this was wrong-headed, but she says that her physician told her that vaccines cause autism (which flabbergasted me).”

          Have you meant some of the Congressional members of our Science Committee?

  3. I’ve been knocked out twice in my 37 years. Once was in a Thanksgiving football game with friends and once was when I played catcher in our local baseball league and a guy plowed into me while he was stealing home.

    The baseball injury was a fluke. The football injury was par for the course. I’m pretty opposed to tackle football these days, even though I am the world’s biggest hypocrite whenever Notre Dame is playing or my beloved prep school alma mater. Not to mention how much I love MMA where KOs are sort of the whole point.

    I think we’re maybe a decade away from seeing the game radically change, but darned if I know what that will look like.

    • I feel the same way — I think there’s enough data about the long-term effects of football-induced brain damage that the NFL needs to either fold or take responsibility for insuring its players for life (in which case, it would fold.) But I’m still going to watch the 49ers play the Bears tonight.

        • You like Notre Dame? No wonder we so often disagree with one another.

          • Not this Catholic. Maroon and gold through and through.

            Wait. No. I hate my alma mater. Purple and gold it is!

        • Along with the regular refs, and those replacements were pathetic. “It’s illegal batting. No, it’s an incomplete pass. Actually, it’s intentional grounding. On further reflection, it’s a safety.”

    • I received a concussion (and a dislocated jaw) playing softball. I was (also) the catcher, and it was a foul-tip popup. I came up out of the crouch, took off my mask + skullcap so I could see the ball – but didn’t see that the batter was bringing the bat BACK around after swinging. She laid that metal right up the side of my head.

      I was lucky my jaw wasn’t broken.

  4. Can you say something briefly: “For the record, I think playing football is not advisable, but I totally understand how much it means to you. Given that, I’m just going to try and help you do it safely,” and then launch into the concussion stuff?

    • This is actually only slightly stronger than what I say already. I don’t go quite so far as to say it is not advisable, but I do state that it is quite risky for certain serious injuries.

      However, I don’t vary it by age, and wonder if I should start.

  5. Our oldest boy played on a CYO team in the 6th grade.

    For a lot of reasons, it ended up being a very positive experience for him. I don’t know that he loved it (he opted not to play the next year and every year since), but he did seem to relish learning how to be part of a bigger community working toward a common goal. I definitely counted it as an agent of maturity for him at the time. He was never injured, and in fact he used the two week preseason “bootcamp” as a springboard to become the healthy eating/working out daily guy he is now.

    That being said, the really high number of kids on his team that ended their season early do to being put it one kind of cast or another was truly shocking for me. I might be forgetting one, but I can’t remember a single game they played where at least one kid from either team wasn’t carried off the field by parents and driven to the ER.

  6. “The other is that my son is never to play tackle football.”

    What about your daughter?

  7. Tangentially related question: how do you feel about rugby (thinking for the 14-and-up crowd)? The students I know LOVE the sport, and both of my sisters played, but it seems to generate an awful lot of injuries…. not concussions, so much, but broken limbs at a rate of ~ 1 per game, especially at beginner levels (like in high school).

    Do I just know a lot of fragile people, or does that rate of breakage hold true in your experience as well?

    • I wish I had something vaguely meaningful to contribute, but I haven’t had many patients who’ve played it at all. I don’t think any of the local high schools have teams. Those few I have had have played it in college, where my concerns are obviously tempered a great deal by their age.

      • I played Rugby for several years while at a minor English Public School. In the time that I played (recognizing that if I had a position it was 3rd reserve for the 3rd 30) it was a rare game when someone left the field due to significant injury.

        On the other hand I was asked if I would advise a team when I first came to the US. In the first game that I went to, one of the players was carried off with a broken leg. I declined the invitation.

        My conclusion at the time was that football players in the USA are raised with much more padding that is used in Rugby. (I remember that we used virtually none). As a result they tended to tackle harder and more violently, anticipating padding that wasn’t there. It was not my cup of tea!

        • That’s a good point and one of the solutions that has been proposed for American football is to go back to leather helmets.

        • It’s also the style of tackling. In rugby you don’t just run into a guy, bash him and then hope to bring him down. You instead go low, below the waist, grab the thighs, suddenly restricting his movement and causing him to fall forward. If he has been trained, he falls safely into something that resembles the recovery position. In mys school days, we didn’t even wear padding. I’ve been injured more seriously walking along the side walk or down the stairs at home (severe sprains, fractures of the ankle)

  8. I see far too many kids every year with concussions, and the potential for serious or catastrophic injury is simply too great to be justified for the sake of a game.

    The game may not be worth the concussions, but the girls are.

    • Kickers get hurt too. They are spindly, vulnerable targets out there being rushed by 11 guys while there are only 9 defending them. In college and NFL games, it’s typically at or near the time that numbers game inevitably moves into the defense’s favor, the kicker is often in his most awkward, off-balance, and extended position with the ball flying away just in time. Aggressive special teams defenders have been known to “follow through” and tackle the kicker in an effort to block the kick. Place kickers sometimes need to play at quarterback. Punters need to tackle.

      I think it’s the case that kickers get less contact, and get hurt, less often than other positions. But it’s hardly risk-free.

  9. Has anyone ever had a concussion? They’re really frickin’ scary. I estimate I’ve had 5… 2 officially diagnosed and 3 I’m pretty sure of. The thing is, you often don’t realize you have one until after the fact. You get your “bell rung”, your head hurts, maybe a headache. Meh, whatever. Four or five days later, you get back to feeling normal and realize how shaky the past few days were, if you remember them at all.

    While three of mine were related to football, only one occurred actually playing football (flag intramural league in college… Mom similarly banned me from playing the real deal growing up); the other two occurred as a result of drunken tailgating. The first one I got during a rock fight with my brother around 5 years of age. The fifth and final one was also the result of drunken bumbling, albeit chasing girls, not teams.

    • Case in point… this literally JUST happened…

      Kazzy: Would you let our kid play football?
      Zazzy: We’ve had this conversation.
      Kazzy: We have?
      Zazzy: Yes.
      Kazzy: I’ve had too many concussions to remember such things.
      Zazzy: And that answers that.

  10. I still remember a conversation between my mother-in-law (whom I get along famously with), my wife, and I concerning our still-infant son and football. My MIL looked right at me and declared, “He will NOT play football!” My wife agreed. I just kind of cocked an eyebrow at them and said, “He’ll play whatever he wants to play.”

    And he does play what he wants to: piano and violin. Not quite as many concussions in the music world.

    • Watch out when he loses track and tries to put the piano under his chin.

  11. Point him toward rugby. I don’t have any hard data to back it up, but in 15 years around the game I think I have maybe seen a dozen clinical concussions. The fact that the big rugby playing nations (Europe and The Commonwealth) don’t seem to have the CTE issues leads me further to think it is true.

    I do know that the way the game is played the force of collisions is greatly reduced, on average. Mostly because of the short distances involved in the tackle, but also since the goal of the tackle is very different. Besides, when you’re not wearing pads, you’re not likely to fling yourself violently at someone, given an inherent understanding of Ike Newton’s 3rd law.

    • Rugby doesn’t have the illusion of protective equipment so the players don’t fling themselves into each other the same way. Rugby beats the crap out of your nose, ears and teeth but leaves our brain and superstructure mostly alone. Football keeps you pretty but smashes up the works inside the brain case and joints.

      • Well, looking pretty is what counts. What’s on the inside doesn’t matter.

        Now, if you want an asymmetrical face and have your brain rattled around inside your skull, take a look at boxing.

      • Despite years in the front row, I still have pretty ears due o my judicious application of electrical tape.

  12. Russell, I don’t know if you check it out but the Canadian Acadamy of Pediatrics has some position papers you might find interesting, if not helpful in that it doesn’t deal with football. In Canada, the dangerous sport is hockey and concussions are a hot topic. Here are is the key articles’ links for you:

    http://www.cps.ca/documents/SportsReadiness.pdf Note that the authors say “entry-level football” may be appropriate for “late childhood (10-12 years)”.


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